1. Phlebotomy- Blood Draw for Nursing

2. Phlebotomy for Nursing Staff
Welcome to the Phlebotomy Module
for Nursing.
It is important to establish a routine involving key steps for safety and accuracy of blood sampling.
Review the following slides for recommended practice of phlebotomy.
Bench marked with area facilities August 28, 2014: Adventist Health and Kaweah Delta utilize ED Techs who are certified in phlebotomy and nursing for blood draws in the ED. CRMC and Clovis Community utilize department based lab phlebotomists for the majority of their draws especially legal draws. Nurses can draw their own but usually don’t.

3. Venipuncture Resources
The following procedure is from the
Tulare Regional Medical Center Laboratory
Specimen Collection Resource Manual and Nursing Procedure for Blood withdrawal.
The procedure is available on the district intranet: Clinical Procedure Tab, open the index and click on ‘Blood Withdrawal’ and/or
‘Lab Venipuncture Procedure’.
Venipuncture procedure from Tulare Regional Medical Center Laboratory Specimen Collection Department.
References: 1. Phlebotomy Handbook 7th Edition 2005.
2. National Committee for Clinical Laboratory Standards (NCCLS) 1998.
3. WHO guidelines on drawing blood 2010.

4. Venipuncture Guidelines
Licensed nursing staff performing venipuncture for blood withdrawal will demonstrate and maintain competency necessary to promote safe patient outcomes using the guidelines set forth from the TRMC Laboratory.
Must have a physician order for laboratory studies.
No more than two attempts shall be performed by nursing before lab personnel are notified.
All peripheral blood cultures will be drawn by laboratory staff only. Pediatric patients will also be drawn by laboratory.
If drawing for type and cross, band the patient per lab procedure.
Clinical Services Standard of Care Guidelines for Blood Withdrawal.

5. Venipuncture Procedure
Introduce yourself to the patient. Explain what you will be doing (“I will be drawing your blood sample for ______ tests ordered by the physician, do you have any questions?”)
Identify the patient (using 2 identifiers: name, date of birth, medical record #, account #).
Position the patient comfortably, arm extended and supported.
Assemble the necessary equipment (next slide).

6. Equipment and Supplies
Single use Tourniquet
Appropriate disinfectant (alcohol, chlorhexidine)
Adhesive tape or bandage
Appropriate needle (20-21 gauge needle- smaller needles may hemolyze red blood cells)
Gloves (non-sterile)
Syringe or Vacutainer holder
Appropriate collection tubes
Specimen labels or water resistant pen for labeling

7. Wash Hands
Use soap and water or an alcohol based hand sanitizer. Wash carefully, including wrists and between fingers for at least 30 seconds.
Apply non-sterile gloves.

8. Select the Site
Preferred veins: Cephalic vein and Median cubital veins are used most often. Wrist, hand and ankle veins are also acceptable for venipuncture.

9. Select the Site cont.
Palpate and trace the path of the selected vein with the index finger. Unlike veins, arteries are more elastic and have a thick wall. Thrombosed veins lack resilience, feel cord-like and roll easily.
Note: Do not ever draw a blood sample above an IV line.

10. Select the Site cont. Trouble shooting techniques:
If superficial veins are not readily apparent, blood can be forced into the vein by massaging the arm from wrist to elbow. Tapping sharply at the vein site with the index and second fingers a few times will cause the vein to dilate. Application of heat to the site may have the same result. Lowering the extremity over the edge of the bedside will allow the veins to fill to capacity.

11. Cleanse the Site Cleanse the venipuncture site:
For routine venipuncture, use 70% isopropyl alcohol.
If blood Alcohol level is ordered on the patient, use iodine only.
Blood culture collection will be completed by Lab personnel only.

12. Tourniquet
Apply the tourniquet three to four inches above the selected site.
Never leave the tourniquet on for longer than one minute. To do so may result in hemoconcentration which will affect blood test values.

13. Perform the Venipuncture
Attach the appropriate needle onto the syringe or Vacutainer holder.
Secure the vein either by placing the thumb below the venipuncture site and pulling the skin towards you or by “bracketing” the vein with the thumb and index finger.
Position the needle and syringe (or
Vacutainer holder) in line with the
selected vein. The syringe should
be held at about a 15-degree
angle with the patient’s arm.

14. Venipuncture cont.
Using a smooth motion, insert the needle into the vein. A sensation of resistance will be felt, followed by ease of penetration as the vein is entered.
If blood does not enter the syringe:
Repalpate the vein, secure it once more and attempt to direct the needle into it.
If blood is not obtained, a second venipuncture may be performed at a different site.

15. Venipuncture cont.
Once blood enters the syringe, pull back slowly on the plunger until the desired volume of blood has been obtained.

16. Venipuncture cont.
If using the syringe method, immediately place the blood in the appropriate tubes.
According to the National Committee for Clinical Laboratory Standards (NCCLS) document: “Procedures for the Collection of Diagnostic Blood Specimens by Venipuncture”, the order in which the tubes should be filled is as follows:

17. Multi-specimen Order of draw
#1 Blood culture bottles (if drawn)
#2 Blue Top: coagulation determinations. Fill completely to line on tube.
#3 Red Top: plain tube, non-additive.
#4 Gold Top: gel separator tube
#5 Green Top: Heparin tube. Used for plasma determinations in chemistry.
#6 Lavender Top: EDTA additive. This is primarily used for Hematology & Transfusion services.
#5 Gray Top: Oxalate/Fluoride tube. Fluoride inhibits glycolysis, used for glucose (for DKA) patients or for Lactic Acid (on ice).
NOTE: This order of draw will eliminate significant carry over of the anticoagulants that may adversely affect patient results.
Gently rock the tubes back and forth 8 times to mix.

18. Vacutainer Method:
Once the vein has been entered, advance the tube into the Vacutainer needle with your free hand. When the first tube is filled, remove it and insert another tube until the desired tubes have been filled (same order of fill as previous). Be sure to grasp the Vacutainer holder firmly while changing tubes to prevent needle movement.

19. Invert Tubes
Gently rock (or invert) the filled tubes back and forth several times to assure mixing of anticoagulants (this can be done as the next tube is filling).

20. Venipuncture cont.
When the desired volume of blood has been withdrawn, gently untie the tourniquet, place a cotton ball or gauze pad over the puncture site, and withdraw the needle.
As soon as the needle is withdrawn, apply pressure to the puncture site. Pressure must be applied until the flow of blood has stopped.

21. Venipuncture cont.
Note: failure to apply adequate pressure may result in bruising or the formation of a hematoma, which will make subsequent venipunctures more difficult and more painful.

22. Label Specimens
Label all specimen tubes at the bedside using 2 patient identifiers.
Mark date & time of specimen draw.
Label as drawn by RN (initials and employee #).
Place specimens in biohazard bag.
Send to lab.
Note: If using patient label, place on top of existing label, leave a window for viewing blood levels in tube (for checking appropriate fill amounts).

23. Venipuncture follow up
Activate the safety device for the needle used and discard in the Biohazard Sharps Container provided in the patient room.
Remove gloves and wash hands after each patient.

24. Specimen Timeframes
For best results return blood specimens to Lab ASAP after draw. However, please note the following times for processing acceptable specimens for testing:
Ammonia – the heparin (green top) tube should be completely filled, on ice, and delivered to Lab immediately for processing.
BNP – whole blood EDTA (lavender top) tube is acceptable for 7 hours at room or refrigerator temp.
CBC the EDTA (lavender top) tube must be processed within 24 hours of collection. (Note: if CBC and type & cross ordered, may need to draw 2 lavender top tubes- check with lab).

25. Specimen Timeframe cont.
Creatinine Clearance – (green top or red top) must be collected sometime during the urine collection, or immediately thereafter (within 1 hour). Inform lab of patient height and weight (required).
ESR – whole blood EDTA (lavender top) must be tested within 2 hours of collection.
Lactic Acid – sodium fluoride/potassium oxalate (gray top) should be placed on ice after collection and delivered to Lab immediately for processing.

26. Specimen Timeframe cont.
PT – sodium citrate (blue top) uncentrifuged – OK for 24 hours; centrifuged – must be tested within 4 hours of collection. Fill tubes completely.
PTT – sodium citrate (blue top) must be tested within 4 hours of collection. Fill tubes completely.
Renal Panel (Basic Metabolic Panel) – lithium heparin (green top or red top) must be tested within 2 hours of collection.

27. Specimen Timeframe cont.
Panel 12– (Comprehensive Metabolic Panel) lithium heparin (green top or red top) must be tested within 2 hours of collection.
Electrolytes – (Sodium, Potassium, Chloride, CO2) lithium heparin (green top or red top) must be tested within 2 hours of collection.
All Enzymes - lithium heparin (green top or red top) must be tested within 2 hours of collection.

28. Specimen Timeframe cont.
Glucose:
Uncentrifuged green or red top glucose will decrease by 5-7% per hour.
Serum that has been separated from the red blood cells and refrigerated must be tested within 8 hours of collection.
Gray top must be tested within 3 days of collection.
Always for best results remember to return all blood specimens to Lab ASAP after draw.

29. Pediatric Specimen Collection
Every reasonable attempt will be made to obtain the required specimens from a pediatric patient in order to perform the tests requested by the ordering physician.
If a child resists the parents/guardian will be informed of options (holding child, wrapping in a papoose, etc.), always ensuring the child’s safety.
Notify the physician if unable to obtain the ordered blood sample.
Be aware of the amounts of blood required for ordered tests (drawing too much blood at one time from a pediatric patient can pose a health risk).

30. Pediatric Specimen cont.
Use the following guidelines to determine maximum blood volumes permitted age 0-14 years.

31. Phlebotomy Competency
All nursing staff performing phlebotomy will complete the attached competency- obtain from Education or Lab:

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